Gastric banding: Pros and cons of Christie's surprising choice

May 7 (Reuters) - New Jersey Governor Chris Christie'schoice of gastric banding has prompted questions about why heopted for a weight-loss procedure less favored by bariatricsurgeons and patients.

Lap-Band stirred excitement a decade ago when theanti-obesity device was introduced in the United States. Theadjustable silicone cuff filled with saline is placed around theupper part of the stomach. That creates a small pouch less than1 inch (2 centimeters) across that limits how much food one canconsume at a sitting. The patient also feels full sooner, andcan thereby shed weight.

In early 2011 the U.S. Food and Drug Administration extendedthe approved use of Lap-Band to include use by some people whoare barely obese. At the time, manufacturer Allergan Inc, betterknown for its Botox wrinkle treatment, said the new criterionwould make 26 million Americans eligible for the product.

The company's high hopes were quickly dashed, however, whensales plunged from almost $300 million in 2008 to $160 millionin 2012 because of concerns about Lap-Band's effectiveness. Moststudies find that although some gastric-band patients lose 100pounds or even more, in general gastric bypass produces more,and more enduring, weight loss. Allergan is now trying to find abuyer for the product line and earlier this year said itconsidered Lap-Band a "discontinued operation."

Another important reason for Lap-Band's decline is growingevidence that a form of bypass surgery called Roux-en-Y may bemore effective in treating type 2 diabetes, which typicallydevelops in adulthood and is linked to obesity.

Christie has not explained why he chose banding instead of abypass, but experts who were not involved in his case pointedout several possibilities, including that he may not have neededto treat diabetes. In the past, Christie has described himselfas healthy despite his weight.

"If he didn't have any other medical problems, that couldhave come into the decision-making," said Dr Jaime Ponce,president of the American Society for Metabolic & BariatricSurgery.

Gastric banding is also a simpler procedure. Its rate ofmajor complications is 0.9 percent, reports the American Societyfor Metabolic & Bariatric Surgery, compared to 3.6 percent forgastric bypass. That means less likelihood of post-operativeinfection, blood clots, blood loss or other serious problems.

About 200,000 people in the United States had weight-losssurgery in 2009, the last year for which data are available,according to the bariatric surgery society. Gastric bypassaccounted for about half of the procedures and lap banding forabout one-quarter.

REROUTING THE DIGESTIVE SYSTEM

The three main forms of bariatric surgery cost $11,500 to$26,000, according to the surgery society. Medicare, the federalgovernment's health insurance program for the elderly anddisabled, pays for them in patients who have a body mass index(BMI) of 35 or greater plus one additional obesity-relatedcondition, such as diabetes or sleep apnea, and who meet certainother requirements. Many commercial insurers have similarpolicies.

In gastric bypass, a surgeon reroutes the digestive systemso that the stomach empties directly into the middle of thesmall intestine, bypassing a section called the duodenum andjejunum. That has the effect of limiting the absorption ofcalories. And since the surgery also makes the stomach muchsmaller, it limits how much someone can eat at a time.

In sleeve gastrectomy, a surgeon staples the stomachvertically. That has the effect of decreasing its volume by morethan 85 percent, creating a tube- or banana-shaped pouch that,like banding, reduces the amount of food that can be consumedand absorbed.

Complications from the banding cuff include the possibilitythat it will erode the stomach or slip out of place, requiringcorrective surgery, said Ponce, who is also the co-medicaldirector for bariatric surgery at Memorial Hospital inChattanooga, Tennessee.

Banding can reduce the severity of type-2 diabetes only ifit leads to significant weight loss. But Roux-en-Y targets theunderlying metabolic causes of diabetes, and blood glucoselevels improve even before there is significant weight loss,said Dr Francesco Rubino of Catholic University in Rome, apioneer in Roux-en-Y.

The more modest procedure also often fails to produce thesignificant and enduring weight loss that patients hope for."One of the unfortunate reactions the body has to (smallerintake) is to decrease its energy expenditure," said Rubino.

As the body adjusts its metabolism to near-starvationconditions, it burns fewer calories to maintain basicmetabolism. That can cause weight to plateau before patientsreach their ideal size.

Even more distressing to gastric-band patients, they canregain weight. That can happen if they force too much food intothe stomach, stretching it and thereby loosening the band, or ifthey eat mostly calorie-dense foods.